Palliative care in an Intensive
Care Unit
JOSIEN SCHOO
NURSE PRACTITIONER PALLIATIVE CARE
RIJNSTATE HOSPITAL ARNHEM
THE NETHERLANDS
Introduction
2
Definition palliative care and intensive/critical care
Literature review palliative care on an ICU
Desicion-making
Family support
Symptommanagement
Role of the consultation team palliative care
Outcomes of qualitative study with nurses from the
ICU Rijnstate hospital by Josien Schoo
Definition palliative care
3
Approach that improves quality of life of patients
and their families
Facing problems associated with life-threatening
illness
By prevention and relief of suffering through early
identifation, assesment and treatment of problems
Physical, psychosocial and spiritual problems
4
Palliative care can be provided in any patient setting
By an interdisciplinary team
Including ICU
Definition intensive care
5
Provides comprehensive and continuous care for
persons who are critically ill and who can benefit
from treatment
Literature review
6
USA: 20 % of all deaths occur on an IC
Most IC deaths follow a desicion to forgo life-
sustaining treatment
Most of the cases patients have no desicional
capacity ( less than 5 %)
Family members play an important role in daily
desicion-making
Literature review
7
Patient orientated in the IC includes family
orientated
Literature review
8
Importance of palliative issues in intensive care
Frequency of death
Unpredictability of death
Complex technology
Interdisciplinary desicion-making
Threath of discomfort, distress and loss of dignity
Literature review
9
Desicion-making ICU often difficult
Culture IC is saving lifes
Transition from curative to palliative care is often sudden and
in a short time
Dying process more dramatic and in a shorter time
Unstable situation
Great variety between clinicians and nurses about goals of care
Nurses think often sooner about withdrawl life-sustaining
therapy
Literature review
10
Family support on an ICU is complex
Studies show that the needs of family are inconsistently met
Universal problem
Improving communication can reduce family member
symptoms
Nurses play an important role
Literature review
11
Important issues for family support
Desire for information exchange
Timely communication about prognosis and goals of care
Timely communication about withdrawing curative
interventions
Literature review
12
Good clinician-family communication
Support for surrogate desicion makers
Majority of improving family satisfaction is under direct
control of clinician/nurse
Routine palliative care consultation (quality of care and cost
effictive)
Literature review
13
Communication on an ICU
Family rate communication one of the most important skills of
a clinician
As most important as clinical skills
70 % talking and 30 % listening
Satisfaction family higher when clinician talks less and listens
more
All team members must be informed about medical situation
and goals of therapy
14
Literature review
15
Important issues for communication ICU
Family meeting important place for communication
Choose the right time and early in the process
Use a structured way to lead a family meeting (VALUE)
V= Value statements made by family
A= Acknowledge family emotions
L= Listen to family members
U= Understand the patient as a person
E= Elicit questions from family members
Literature review
16
Important issues for communication ICU
Respond to emotions (NURSE)
Withdrawl of life-support is not the same as withdrawl care
N= Naming
U= Understanding
R= Respecting
S= Supporting
E= Exploring
Literature review
17
Symptommanagement on an ICU
Not optimal, has to be improved
Symptoms best assessed through direct communication
Most patients are sedated, more complex
Lack of knowledge about symptommanagement in the last
days of life
Literature review
18
Symptommanagement
Shortness of breath, pain, anxiety, delirium
Balance between goals of comfort and goals of intensive care
Current use of analgesics and sedatives do not hastening death
Alleviation of pain and suffering is crucial for good quality of
end of life care
Intensive care nurse
19
Symptommanagement patient
Communication within the team
Communication process with patient and family
Supporting family
End of life care during last hours
Fore front of integrating both types of care
Consultation team palliative care
20
Respect for the ICU team
Understanding and honoring perspective ICU
clinicians and nurses
Find a way to identify ICU patients who need
palliative care
First educate basic elements of palliative care
Consultation team palliative care
21
Second educate the ICU team in identifying palliative
care patients, symptommanagement,
communication, bereavement and grief family
For more complex situations advice the ICU team
Palliative care on the ICU of Rijnstate hospital
22
Qualitative study
23
Descriptive and qualitative study from november
2009 – march 2010
Semi structured interviews with 8 nurses from IC
Rijnstate hospital
Qualitive study
24
Analyzing data in a structured manner using
Kwalitan sofware
Phases in analyzing
Open encoding
Axial encoding
Selective encoding
Qualitative study
25
3 main themes
Withdrawing life-sustaining therapy and stopping curative
treatment
Alleviating symptoms and providing comfort for the patients
(symptommanagement and supporting the process of dying)
Support for family on an ICU (attending and informing family
by nurses, doctors and other healthcare deliverers)
Conclusion
26
Palliative care on the ICU of Rijnstate hospital
includes namely:
Management of symptoms
Providing support to the patient to make the process of dying
as comfortable as possible
Offering support and giving information to the patients family
Conclusion
27
The conclusion matches with a few key points of the
definition of palliative care by the WHO (2002)
Affirms life and regards dying as a normal process
Intens neither to hasten or postpone death
Provides relief from pain and distressing symptoms
Integrates the psychological and spiritual aspects of patient
care
Offers a support system to help the family cope during the
illnes and in their own bereavement
Uses a team approach to adress the needs of patient and family
Recommendation
28
Implenting a protocol for palliative care for patients
on the ICU
Palliative care more earlier in the process
More study on the ICU in how family experiences the
desicion-making process and the dying of their loved
one
The end
29
Education is a powerfull tool
Palliative care not only for the actively dying patient
More research is necessary to understand palliative
care on an ICU
Impact of palliative care on an ICU
Length of stay
Costs
Family satisfaction
30
